PROJECT SUMMARY/ABSTRACT: This two-phase project is designed to achieve the Cancer Moonshot objectives by reducing the burden of CRC on the US population. Specifically, we aim to improve CRC screening rates, follow-up colonoscopy, and referral to care in rural Medicaid patients by implementing a direct mail fecal testing program with targeted outreach and patient navigation for follow-up colonoscopy. We leverage partnerships with the Oregon Rural Practice-based Research Network (ORPRN), Kaiser Northwest Center for Health Research, and Medicaid Health Plans and deliver training and implementation support to participating rural primary care clinics using practice facilitation. In total, we anticipate working with 30 organizations to facilitate implementation with 130 primary care clinics (reaching 17,000+ rural Medicaid patients). In Phase I (Year 01), we will conduct a milestone driven pilot to build the necessary infrastructure for a large-scale implementation-effectiveness trial, including adapting the clinic-health plan-vendor supported direct mail program for rural Medicaid patients that have not established care and/or never been screened; conducting a pilot study testing the feasibility and acceptability of patient navigation to support follow-up colonoscopy following an abnormal fecal test; engaging Medicaid Health Plans and recruiting 30 primary care clinics located in rural and frontier counties in Oregon; and developing the training and support materials needed to implement a large-scale trial in these settings. In Phase II (Years 02-05), we will conduct an implementation-effectiveness study using a quasi- experimental stepped wedge design in 30 rural primary care clinics using program training and practice facilitation to support implementation. As in the pilot, the intervention combines: (1) a clinic-health plan- vendor supported direct-mail fecal testing program with targeted outreach for patients who have never been screened or who have yet to establish care and (2) patient navigation for those who are referred for colonoscopy as either the primary screening or for follow-up from an abnormal fecal test. We will evaluate effectiveness, implementation, and maintenance of the intervention through quantitative and qualitative measures. Results from the implementation study will inform scale-up of the program through partnerships with 20 regional and national organizations that serve rural/frontier primary care clinics using webinars, train-the-trainer workshops and collaborative learning activities using the ECHO (Extension for Community Healthcare Outcomes) model.